SURGICAL TREATME.NT OF ABDO3IINAL DROPSY FOLLOWING CIRRHOSIS OF THE LIVER. — The operation devised by Talma consists of an abdominal section, preferably between the umbilicus and ensiform cartilage, evacuation of the ac euinnlated fluid, and scraping of the parietal peritoneum with a curette or rubbing off the epithelium with a gauze sponge. The superior surfaces of the liver and of the peritoneum covering the diaphragm are also rubbed. The omen tum for three or four inches around the incision is then stitched to the parietal wall, and is included in the sutures which dose the abdominal incision. A broad surface is available for adhesions, and it is the additional collateral cireu lation thus obtained which constitutes the main feature of the operation. Its formation, however, is comparatively slow, and it is frequently necessary to tap the patients several times after the oper ation, before the collateral circulation is complete.
Since the first operation for cirrhosis of the liver, 13 have been performed. Of these, 5 have recovered, 2 were im proved, in 1 there was no change, and 5 died. Operation is indicated in cases in which there is a distinct mechanical hindrance in the portal circulation with recurring ascites. The technique consists of a small incision into the abdominal cavity, through which a careful explora tion is made of the liver, gall-bladder, and the surrounedng parts. The peri toneum is curetted over the anterior sur face of the abdomen, and the great omen tum is attached by sutures to the ab dominal wall. The peritoneum has its epithelial covering removed over the lateral and anterior portion on the left side of the abdomen, to which the spleen is likewise attached. A glass drain is then inserted, and all ascitic fluid of the abdominal cavity is removed. This drainage is continued until no further fluid is formed, which shows that the collateral circulation has been estab lished. F. Friedmann (Centralb. f. d. Grenzgebiete der Med. u. Chir., Aug. S, 1900).
The operation for creating compensa tory circulation in hepatic cirrhosis is indicated in those cases in which the collateral circulation is not sufficiently established to relieve the rapidly in creasing ascites. Although the cases operated on by Talma himself proved fatal, it was successful in 65 per cent. of eases operated by other surgeons. Two personal cases reported in which Talrna's operation was performed. Two months later ascites again developed, six litres of fluid having been removed by tapping. After that the patient felt much stronger. The second ca.se pre sented a history of chronic alcoholism, and was far advanced in the disease when Talma's operation was performed.
Ire improved after it for about two weeks, when lie commenced to decline rapidly, and died within forty-eight hours. It is a simple and harmless method of treating ascites. N. M. Ben isovitch (Vratch, Feb. 17, 1901).
All well-attested cases of cirrhosis presenting ascites should be operated upon under local ancesthesia. Frazier's
table of fifteen cases reproduced, per sonal case being the fifteenth in the table. Frazier's list shows that 75 per cent. of recoveries had taken place. J. J. Jelks (Med. Record, -Mar. 23, 1901).
Case of hepatic cirrhosis in which Talnia's operation was performed about a year ago. The liver and spleen were in the same condition; the circulation had improved; collateral circulation was well established; and the ascites did not recur. Scherwincky (Med. Obos renije, Mar., 1901).
Two cases of cirrhosis ot the liver in which Talma's operation was performed. The operation may be of benefit in two ways: First, by diminishing the con gestion of the liver; second, by increas ing, the vascular supply of the surface cells so that they may undergo com pensatory hyperplasia. The ascites is due ahnost exclusively to the portal ob struction. Drainage may be made through the larger opening. The abdo men should be encircled with broad ad hesive strips. Twenty-two cases have been recorded, giving the following re sults: Immediate death, 5; ultimate death, 3; unimproved, 3; improved, 2; recovered, 9. The operation strongly recommended. F. Packard and le Conte (Amer. Jour. Med. Sei., Mar., 1901).
Statistics show- that six eases at least have been cured of a.seites by stitching the omentum to the anterior abdominal wall, and which remained well for a period of two years or more. Six others were relieved of this symptom for from two to six months, but died, either with ont a return of the ascites or have been under observation long enough to dem onstrate that the cure is permanent. A ease of limmorrhage from the alimentary canal Wit promptly cured by the above operation. Thirty-eight cases recovered from the operation. and, when we con sider that in the majority of instances these patients were in the last stages of an incurable disease and would lia.ve died within a few weeks, it seems that if these cases were taken earlier there would have been more encouraging re sults. G. E. Brewer (Medical News, Feb. 8, 1902).
Biliary Cirrhosis.
Under the term "biliary cirrhosis" two distinct conditions are to be included:— 1. A condition rare, clinically, but pro duced experimentally in the lower ani mals by Charcot and Gombault by lig ature of the common bile-duct. A condi tion in which obstruction of the larger bile-ducts is followed by inflammatory condition of the intrahepatic and extra hepatic bile-ducts, and the later deyel opment of fibrous tissue around them.
2. A condition in which the liver is found permanently enlarged, with the development of much rather loose and non-contracting fibrous tissue, in which, as evidenced by the accompanying jaun dice, there is some hindrance to the free flow of bile through the smaller ducts, for no obstruction of the extrahepatic bile-ducts is to be recognized.
A further characteristic of this form is the peculiar extensive development of the already-described new bile-ducts in the hyperplastic fibrous tissue.